Discussion of interesting or befuddling cases related to pulmonary and critical care medicine.

Monday, December 19, 2005

Abnormal CT scan

This is an 83 y/o man sent to us by our CT surgeons. Two months ago he had a tracheo-bronchitis treated by his PCP. A CxR showed a subtle abnormality on his L lung and that was better seen on a CT scan. He is now assymptomatic but has a persistent abnormality on his L lung on a repeat CT scan (see below, this was done roughly 6 weeks after the first one).He is a former smoker (quit in 1967) with no other remarkable exposures.Exam is fairly normal.PFTs showed mild COPD (FEV1~70% with normal TLC, increased RV and DLCO ~60%).The surgeons thought we might want to see him before cutting anything out.What would you do next?

3
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Anonymous
said...

This is a dump from surgeons. Ask pt what he wants and document. If there is any doubt about his competency, involve DPOA/family members for the decision making. Most of the elderly do not want surgery even if it is a curable cancer. And I do not blame them. QOL is the most important thing at this stage, not the longevity.

"Most of the elderly do not want surgery even if it is a curable cancer"

With all due respect, where is the data to support this? This has not been my experience at all.

Maybe the surgeon's just wanted to get a medical opinion before offering surgery. I'd put him on bronchodilator, get a PET scan to make sure this is resectable, and recommend resection. The pre-test probability that this is cancer is ~80% if indeed this was not present on old films.

I agree; this sounds like an otherwise healty 83 year old and, unless there are compelling reasons otherwise, should receive the standard of medical care. In this case, I think a staging PET is reasonable and, and unless unexpected lesions are encountered the patient should be offered the potentially curative surgery.

I can't say that this is definitely not an infection, but I would expect an infection to have resolved radiographically in 6 weeks.